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F 000 INITIAL COMMENTS F 000 COMPLAINT: NJ125510

CENSUS: 58 SAMPLE SIZE: 6

F 580 Notify of Changes (Injury/Decline/Room, etc.) CFR(s): 483.10(g)(14)(i)-(iv)(15)

§483.10(g)(14) Notification of Changes.

(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there

is-(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;

(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a

deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);

(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).

(ii) When making notification under paragraph (g) (14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.

(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-

(A) A change in room or roommate assignment as specified in §483.10(e)(6); or

F 580 8/2/19

SS=D

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

08/02/2019 Electronically Signed

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F 580 Continued From page 1 F 580 (B) A change in resident rights under Federal or

State law or regulations as specified in paragraph (e)(10) of this section.

(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident

representative(s). §483.10(g)(15)

Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

This REQUIREMENT is not met as evidenced by:

C#: NJ125510

Based on interviews, review of the Admission Records (AR), and pertinent facility documents on 7/10/19 and 7/11/19, it was determined that the facility Nursing Staff failed to notify the Resident's family/responsible party for a change in condition, as well as failed to follow the facility's own policy titled "Change in a Resident's Condition or Status" for 1 of 3 sampled residents (Resident #2) reviewed for family notification for a change in condition. This deficient practice was evidenced by the following:

1. According to Resident #2's "Admission Record," the Resident was admitted to the facility on , with diagnoses which included but were not limited to:

HOW THE CORRECTIVE ACTION WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE PRACTICE Resident #2 is no longer in the facility.

HOW THE FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE

All residents have the potential to be affected by this deficient practice.

WHAT MEASURES WILL BE PUT INTO PLACE OR WHAT SYSTEMIC

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F 580 Continued From page 2 F 580 .

According to Resident #2's Minimum Data Set (MDS), an assessment tool dated 1/24/19, Resident #2 had a Brief Interview for Mental Status (BIMS) score of which indicated the

Resident was .

The MDS also indicated that Resident #2 required assistance with Activities of Daily Living (ADLs).

Review of Resident #2's Care Plan (CP) initiated , revealed the following: Under Focus: The resident is at risk for falls. Under Goal: The resident will be free of falls. Under Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.

Further review of Resident #2's CP initiated , revealed the following: under Focus, "at

risk for therapy

related to history of

Under Goal, Resident will not experience any side effects r/t (related to) therapy. Review of Resident #2's PN dated 2/12/19 at 3:00 p.m., written by the Nurse Practitioner (NP) revealed that Resident #2 had

areas noted." In addition, the PN revealed that Resident #2 had an y done of the area which was negative for and patch was ordered to the area daily.

Review of Resident #2's PN written by the Licensed Practical Nurse (LPN #1) dated at 2:59 p.m., revealed that Resident #2 had " from previous fall that is getting better."

NOT RECUR

The ADON or designee will re-educate all nurses on prompt physician and family notification on all incidents and accidents as well as all changes in resident status. HOW THE FACILITY WILL MONITOR ITS CORRECTIVE ACTIONS TO ENSURE THAT THE DEFICIENT PRACTICE WILL NOT RECUR, I.E., WHAT QUALITY ASSURANCE PROGRAM WILL BE PUT INTO PLACE The Unit Manager or designee will report at morning meeting all incidents and accidents as well as changes in status for all residents to ensure prompt physician and family/responsible party notification has occurred.

Results of these audits will be reported to the CQI Committee quarterly.

The CQI committee will determine the need for further audits and/or action plans monthly x 3 months,

COMPLETION DATE

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F 580 Continued From page 3 F 580 Review of Resident #2's PN written by the NP

dated at 3:59 p.m., showed that Resident #2 was seen "sitting on couch complained of worsening

Review of Resident #2's medical records showed no documentation that the Resident had a

area prior to the , PN written by the NP. The medical records did not reveal how Resident #2 acquired the to the

area, or that the Resident's family and / responsible party was notified.

Review of Resident #2's Incident Report (IR) dated at 1:40 a.m., revealed the following:

Resident #2 had a fall and was found on the floor in the Resident's room by the primary nurse. Resident #2 complaint of

was found on the area of the Resident's area.

Resident #2 denies and there were no other injuries noted at the time of the incident. Review of Resident #2's IR dated , showed that the Physician was notified of the fall incident. However, the IR did not reveal that Resident #2's family/ responsible party was notified of the , fall with

.

Review of Resident #2's Progress Note (PN) did not show a documentation for the fall

with or that the

Resident's family and or representative was notified.

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F 580 Continued From page 4 F 580 at 2:00 a.m., revealed the following:

Resident had a fall and was found on the floor in the position by the primary nurse. Resident was (awake, alert and oriented) AAOx2 with periods of , which was the Resident's baseline.

Resident had a found on the top of the Resident's .

checks initiated per policy. Review of Resident #2's IR dated

showed that the Physician was notified of the fall incident. However, the IR did not reveal that Resident #2's family / responsible party was notified of the fall with

Review of Resident #2's PN written by the Licensed Practical Nurse (LPN #1) dated at 12:37 p.m., showed Resident #2 had a

and the NP

ordered a of

the

Further review of Resident #2's PN dated did not reveal that Resident #2's family/responsible party was notified of the

, fall with the of the Resident's when the incident occurred. However, the PN revealed that Resident #2's family came to the facility and requested the Resident to be transferred to the hospital. Review of the Universal Transfer Form (UTF) dated , revealed the resident was transferred to the hospital, the "reasons for transfer" was status post fall with

.

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F 580 Continued From page 5 F 580 2:18 p.m., the ADON stated if a Resident fell or

had an incident, the "LPN usually checks on that Resident and calls the RN to assess the Resident." In addition, the ADON stated, the Resident skin assessment is done; and once the Resident is safe, the physician is notified and if it is determined whether the Resident is going to the hospital or not, then the family is notified." The ADON further stated he/she usually calls the Resident's family at any time, except if it is documented per the family request not to be called late at night.

During an interview with LPN #1 on 7/11/19 at 9:05 a.m., the LPN stated "a resident's family is notified whenever a resident has a fall or any incident, it does not have to be a fall with injury." During a phone interview with LPN #2 on 7/11/19 at 12:40 p.m., the LPN stated Resident #2 had multiple falls and the resident's family is usually called if a resident had a fall. In addition, LPN #2 stated that he/she assumed the " on Resident #2's " were from a previous fall...." LPN #2 further stated that an incident report should have been initiated but he/she could not remember if one was done. The LPN

explained if he/she assumed the was from the previous fall it would have been on the IR. LPN #2 indicated Resident #2's family would have wanted to be notified if the Resident fell or had any incident.

During a post survey phone interview with RN #1 on 7/12/19 at 2:16 p.m., the RN stated that the Resident's family should be notified after each fall or if the resident has an injury. RN #1 stated Resident #2 had a of the

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F 580 Continued From page 6 F 580 remembered Resident #2's "family was very

upset that they had not been called, it was an overlook on my part, it was my fault." RN #1 did not recall Resident #2 having a

area.

Review of the facility's policy titled "Change in a Resident's Condition or Status" with a revised date of 8/15/18, included but was not limited to the following: Under Policy Statement: "Our facility shall notify the Resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.)." Under Policy Interpretation and Implementation #3. "Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when:

a. The Resident is involved in any accident or incident that results in an injury including injury of an unknown source;

b. There is a significant change in the Resident's physical, mental, or psychosocial status."

N.J.A.C: 8:39-13.1(c)

F 609 Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown

F 609 8/2/19

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F 609 Continued From page 7 F 609 source and misappropriation of resident property,

are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§483.12(c)(4) Report the results of all

investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by:

C#: NJ125510

Based on interviews, review of the Admission Record (AR) and pertinent facility documents on 7/10/19 and 7/11/19, it was determined that the facility failed to report an Injury of Unknown origin to the New Jersey Department of Health

(NJDOH), as well as follow the facility's own policies titled "Abuse, Neglect, Mistreatment, and Misappropriation of Property, and Accidents," and "Incidents-Investigating and Reporting" for 1 of 3 sampled residents (Resident #2) reviewed for injury of unknown origin. This deficient practice was evidenced by the following:

HOW THE CORRECTIVE ACTION WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE PRACTICE Resident #2 is no longer in the facility. HOW THE FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE

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F 609 Continued From page 8 F 609 1. According to Resident #2's "Admission

Record," the Resident was admitted to the facility on , with diagnoses which included but were not limited to:

According to Resident #2's Minimum Data Set (MDS), an assessment tool dated , Resident #2 had a Brief Interview for Mental Status (BIMS) score of which indicated the

Resident was .

The MDS also indicated that Resident #2 required assistance with Activities of Daily Living (ADLs).

Review of Resident #2's Care Plan (CP) initiated included the following: Under Focus: The resident is at risk for falls. Under Goal: The resident will be free of falls. Under Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.

Review of the Resident's CP initiated , revealed the following: under Focus, "at risk for

related to therapy related to history of

(DVT)." Under Goal, Resident will not experience any side effects r/t (related to)

therapy.

Review of Resident #2's "Progress Notes (PN)" dated at 7:23 p.m., written by the Nurse Practitioner (NP), showed under

"

when he/she coughs."

CHANGES WILL BE MADE TO ENSURE THAT THE DEFICIENT PRACTICE WILL NOT RECUR

The ADON or designee will re-educate all nurses on prompt notification on all injuries of unknown origin to the Director of Nursing/ designee.

The Director of Nursing will promptly notify the Administrator of all injuries of unknown origin .

All injuries of unknown origin will be promptly reported to the Department of Health and Ombudsman where warranted by the Director of Nursing or designee.

HOW THE FACILITY WILL MONITOR ITS CORRECTIVE ACTIONS TO ENSURE THAT THE DEFICIENT PRACTICE WILL NOT RECUR, I.E., WHAT QUALITY ASSURANCE PROGRAM WILL BE PUT INTO PLACE The Unit Manager or designee will report at morning meeting all injuries of unknown and known origin for residents to ensure prompt investigation and notifications to the appropriate parties has occurred. In addition, review of the twenty-four hour nursing report will be reviewed for any notes pertaining to any such injuries at the morning meeting by the IDCP team. Results of these audits will be reported to the CQI Committee quarterly.

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F 609 Continued From page 9 F 609 Review of Resident #2's PN dated at 3:00

p.m., written by the NP revealed that Resident #2

had " areas

noted." In addition, the PN revealed that Resident #2 had an done of the area which was negative for and patch was ordered to the area daily.

Review of Resident #2's PN written by the Licensed Practical Nurse (LPN #1) dated at 2:59 p.m., revealed that Resident #2 had

from previous fall that is getting better."

Review of Resident #2's PN written by the NP dated 2/16/19 at 3:59 p.m., showed that Resident #2 was seen "sitting on couch complained of

worsening to

Review of Resident #2's Incident Reports (IR's) did not reveal an IR for the to the

area.

Review of Resident #2's medical record showed no documentation that the Resident had a to the area prior to the PN written by the NP. The medical record did not reveal how Resident #2 acquired the to the

area. In addition, the medical record did not reveal that the was reported to the NJDOH.

During an interview with the Assistant Director of Nursing (ADON) on 7/10/19 at 2:10 p.m., the ADON stated that skin assessments are done weekly for all residents, during the assessments the staff are "looking for bruises, skin tear or anything that is not normal to the resident's normal pigmentation."

monthly x 3 months,

COMPLETION DATE

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F 609 Continued From page 10 F 609 During an interview with the NP on 7/11/19 at

9:55 a.m., the NP indicated Resident #2 complained of , and when he/she looked at the area the Resident had a The NP also stated prior to , Resident #2 had no area and had no idea how the Resident got the to the area. During a second interview on 7/11/19 at 10:14 a.m., the NP indicated he/she believed the Resident's nurse was notified of the . During an interview with the ADON on 7/11/19 at 11:53 a.m., the ADON stated "when a new is found they immediately do an incident report and an investigation...."

During an interview with the Director of Nursing (DON), who was new to the facility on 7/11/19 at 12:17 p.m., the DON stated the facility reports "Abuse, Injury of Unknown origin, ...." to the NJDOH. In addition, the DON indicated he/she believed the Resident holding on to his/her due to the may have resulted in the

During a phone interview with LPN #2 on 7/11/19 at 12:40 p.m., the LPN stated Resident #2 had multiple falls and he/she assumed the

on Resident #2's area were from a previous fall...." LPN #2 further stated that an incident report should have been initiated but he/she could not remember if one was done. The LPN explained if he/she assumed the was from the previous fall it would have been on the IR.

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F 609 Continued From page 11 F 609 limited to the following:

Under g. Injuries of Unknown Origin: An injury should be classified as an injury of unknown source when both the following conditions are met:

i. "The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; ... Under "External Reporting: The center will: Initial reporting of allegation: If an incident or allegation is considered reportable, the Administrator or designee will make an initial (immediate or within 24 hours) report to the State Agency. A follow up investigation will be submitted to DON within five (5) working days of the initial date the entity knew or should have known about the misconduct.... Report the results of all investigations to the administrator or his or he designated

representative and to other officials in accordance with State law, including immediate or 24 hour reporting to the DOH, law enforcement and the follow up report to the DOH, within 5 working days ...."

N.J.A.C: 8:39-13.4(c)2(v)

F 610 Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

F 610 8/2/19

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F 610 Continued From page 12 F 610 §483.12(c)(4) Report the results of all

investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by:

C#: NJ125510

Based on interviews, Admission Record (AR) review, and review of other pertinent facility documents on 7/10/19 and 7/11/19, it was determined that the facility failed to investigate an Injury of Unknown Origin, as well as follow the facility's own policy titled "Abuse, Neglect, Mistreatment, and Misappropriation of Property, and Accidents and Incidents-Investigating and Reporting" for 1 of 3 sampled residents (Resident #2) reviewed for injury of unknown origin. This deficient practice was evidenced by the following:

1. According to Resident #2's "Admission Record," the Resident was admitted to the facility on , with diagnoses which included but were not limited to:

According to Resident #2's Minimum Data Set (MDS), an assessment tool dated , Resident #2 had a Brief Interview for Mental Status (BIMS) score of which indicated the

Resident was .

HOW THE CORRECTIVE ACTION WILL BE ACCOMPLISHED FOR THOSE RESIDENTS FOUND TO HAVE BEEN AFFECTED BY THE PRACTICE Resident #2 is no longer in the facility.

HOW THE FACILITY WILL IDENTIFY OTHER RESIDENTS HAVING THE POTENTIAL TO BE AFFECTED BY THE SAME DEFICIENT PRACTICE

All residents have the potential to be affected by this deficient practice.

WHAT MEASURES WILL BE PUT INTO PLACE OR WHAT SYSTEMIC

CHANGES WILL BE MADE TO ENSURE THAT THE DEFICIENT PRACTICE WILL NOT RECUR

The ADON or designee will re-educate all nurses on immediate notification to the Director of Nursing/designee on all suspected cases of abuse, neglect, exploitation, or mistreatment.

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F 610 Continued From page 13 F 610 The MDS also indicated that Resident #2

required assistance with Activities of Daily Living (ADLs).

Review of Resident #2's Care Plan (CP) initiated , included the following: Under Focus: The resident is at risk for falls. Under Goal: The resident will be free of falls. Under Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.

Review of the Resident's CP initiated

revealed the following: under Focus, "at risk for related to

related to history of

(DVT)." Under Goal, Resident will not experience any side effects r/t (related to)

therapy.

Review of Resident #2's "Progress Notes (PN)" dated at 7:23 p.m., written by the Nurse Practitioner (NP), showed under

when he/she coughs."

Review of Resident #2's PN dated at 3:00 p.m., written by the NP revealed that Resident #2

had areas

noted." In addition, the PN revealed that Resident #2 had an done of the area which was negative for ; and patch was ordered to the area daily.

Review of Resident #2's PN written by the Licensed Practical Nurse (LPN #1) dated at 2:59 p.m., revealed that Resident #2 had " from previous fall that is getting better."

begin to conduct a thorough investigation of all such allegations as well as

immediately notify the Administrator.

HOW THE FACILITY WILL MONITOR ITS CORRECTIVE ACTIONS TO ENSURE THAT THE DEFICIENT PRACTICE WILL NOT RECUR, I.E., WHAT QUALITY ASSURANCE PROGRAM WILL BE PUT INTO PLACE The Unit Manager or designee will report at morning meeting all suspected cases of abuse, neglect, exploitation, or

mistreatment for residents to ensure prompt investigating can be immediately implemented by the Director of Nursing. The twenty-four hour nursing report and the risk management section in PCC will be reviewed daily at morning meeting for all documentation that may have occurred that could be suspected as abuse, neglect, exploitation, or mistreatment for thorough investigation by the Director of Nursing.

Results of these audits will be reported to the CQI Committee quarterly.

The CQI committee will determine the need for further audits and/or action plans monthly x 3 months,

COMPLETION DATE

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F 610 Continued From page 14 F 610 Review of Resident #2's PN written by the NP

dated at 3:59 p.m., showed that Resident #2 was seen "sitting on couch complained of

to is slowly resolving."

Review of Resident #2's Incident Reports (IR's) did not reveal an IR for the to the

area.

Review of Resident #2's medical records showed no documentation that the Resident had a to the area prior to the , PN written by the NP. The medical records did not reveal how Resident #2 acquired the to the

In addition, the medical records did not show that the area was investigated.

During an interview with the Assistant Director of Nursing (ADON) on 7/10/19 at 2:10 p.m., the ADON stated that skin assessments are done weekly for all residents, during the assessments the staff are "looking for bruises, skin tear or anything that is not normal to the resident's normal pigmentation."

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F 610 Continued From page 15 F 610 11:53 a.m., the ADON stated "when

is found they immediately do an incident report and an investigation...."

During an interview with the Director of Nursing (DON) on 7/11/19 at 12:17 p.m., the DON indicated he/she was new to the facility but believed the Resident holding on to his/her may have resulted in the .

During a phone interview with LPN #2 on 7/11/19 at 12:40 p.m., the LPN stated Resident #2 had multiple falls and he/she assumed the

on Resident #2's were from a previous fall...." LPN #2 further stated that an incident report should have been initiated but he/she could not remember if one was done. The LPN explained if he/she assumed the was from the previous fall it would have been on the IR.

Review of the facility's policy titled "Abuse, Neglect, Mistreatment, and Misappropriation of Property," dated 7/17/17, included but was not limited to the following:

Under Investigation Components b. Investigation of injuries of Unknown Origin or Suspicious injuries: must be immediately investigated to rule out potential abuse: i. Injuries include, but are not limited to, bruising of the inner thigh, chest, face, and breast, bruises of an unusual size, multiple unexpected bruises, and /or bruising in an area not typically vulnerable to trauma.

Review of a second facility's policy titled "Accidents and Incidents- Investigating and Reporting," dated 8/31/18, included but was not limited to the following:

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F 610 Continued From page 16 F 610 our premises must be investigated .... Under 4.

Investigate Action: a. The Assigned Nurse, DON or department director or supervisor must conduct an immediate investigation of accident of incident. b. The following data, as it may apply, must be included: (2) The nature of the injury/ illness (e.g., bruise, fall, nausea, etc.)....

Figure

Updating...

References

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